Enhanced Care Planning for Patients With Multiple Chronic Conditions

AbstractObjectivesAdvance care planning (ACP) is linked with high-quality clinical outcomes at the end of life. However, ACP engagement is lower among African Americans than among Whites. In this study, we sought to identify correlates of ACP among African American women with multiple chronic conditions for two reasons: (1) African American women with multiple chronic conditions have high risks for serious illnesses, more intensive treatments, and circumstances that may require substitutes' decision-making and (2) identifying correlates of ACP among African American women can help us identify important characteristics to inform ACP outreach and interventions for this group.MethodsA cross-sectional survey was conducted with 116 African American women aged ≥50 years who were recruited from the central area of a mid-western city.ResultsOn average, participants were 64 years old (SD = 9.42). The majority were not married (78%), had less than a college education (50%), and had an annual income of $15,000 (54%). Their mean numbers of chronic conditions and prescribed medications were 3.31 (SD = 1.25) and 8.75 (SD = 4.42), respectively. Fifty-nine per cent reported having talked with someone about their preferences (informal ACP); only 30% had completed a living will or a power of attorney for healthcare (formal ACP). Logistic regression showed that age, the number of hospitalizations or emergency department visits, and the number of prescription medications were significantly correlated with both informal and formal ACP; other demographic and psychosocial characteristics (the knowledge of ACP, self-efficacy, and trust in the medical system) were not.Significance of resultsResults of this study suggest a need for targeted, culturally sensitive outpatient ACP education to promote ACP engagement in older African American women, taking into account age, the severity of chronic conditions, and levels of medication management.

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Opportunities to optimize ehealth technology for patients with multiple chronic conditions

PsycEXTRA Dataset ◽

10.1037/e546872013-121 ◽

2013 ◽

Author(s):

Donna M. Zulman ◽

Emily Jenchura ◽

Danielle Cohen ◽

Eleanor Lewis ◽

Steven M. Asch

Keyword(s):

Chronic Conditions ◽

Multiple Chronic Conditions

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Faculty Opinions recommendation of Association between guideline recommended drugs and death in older adults with multiple chronic conditions: population based cohort study.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.725825161.793511358 ◽

2015 ◽

Author(s):

Andrea Semplicini

Keyword(s):

Older Adults ◽

Cohort Study ◽

Chronic Conditions ◽

Population Based ◽

Multiple Chronic Conditions

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GPS' PERCEPTION OF THE PATIENT ORIENTED INTERVENTIONS AS KEY ELEMENTS OF PATIENT CENTRED CARE FOR PEOPLE WITH MULTIMORBIDITY.pdf

Knowledge International Journal ◽

10.35120/kij2802561a ◽

2018 ◽

Vol 28 (2) ◽

pp. 561-565

Author(s):

Radost Assenova ◽

Levena Kireva ◽

Gergana Foreva

Keyword(s):

Chronic Conditions ◽

Patient Centered Care ◽

Self Management ◽

Multiple Chronic Conditions ◽

Positive Health ◽

Patient Centered ◽

Effective Response ◽

Patient Centred Care ◽

Centered Care ◽

Health Related

Background: Patients with multimorbidity represent a significant portion of the primary healthcare population. For healthcare providers, managing patients with multiple chronic conditions represents a challenge given the complexity and the intensity of interventions. Integrated and patient-centered care is considered an effective response to the needs of people who suffer from multiple chronic conditions. According to the literature providing patient-centered care is one of the most important interventions in terms of positive health-related outcomes for patients with multimorbidity.Aim: The aim of the study is to evaluate the GPs’ perception of patient oriented interventions as key elements of patient centred care for patients with multimorbidity.Material and methods: A cross-sectional pilot study was conducted among randomly selected 73 GPs. A direct individual anonymous survey was performed to explore the opinion of respondents about the importance of two patient-oriented interventions, each one including specific elements of patient-centered care for patients with multimorbidity. The tool was developed as a result of the scoping review performed by Smith et al. (2012;2016). A 5-point Likert scale (0-not at all, 1-little, 2-rather, 3-much, 4-very strong) was used. The data were analysed using descriptive statistics. In processing the data, the software product for statistical analyses - SPSS version 17 was performed for Windows XP.Results: Our results show that both categories - providing patient-oriented approach and self-management support interventions were highly accessed by the respondents. The most frequent categories of interventions identified in our study were Creating individualized and adapted interventions, Performing regular contacts and Reinforcing adherence. Less frequently reported elements such as Considering relatives’ needs and Developing self-management plan are still underestimated by the Bulgarian GPs.Conclusions: The acceptance and understanding of innovative patient-centered interventions adapted to patients with multimorbidity could be accepted as a good indicator for improving health-related outcomes and care for patients with multiple chronic conditions.

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Using Electronic Medical Records and Health Claim Data to Develop a Patient Engagement Score for Patients With Multiple Chronic Conditions: An Exploratory Study

Journal of Patient Experience ◽

10.1177/2374373520981480 ◽

2021 ◽

Vol 8 ◽

pp. 237437352098148

Author(s):

Surachat Ngorsuraches ◽

Semhar Michael ◽

Nabin Poudel ◽

Gemechis Djira ◽

Emily Griese ◽

...

Keyword(s):

Electronic Medical Records ◽

Patient Engagement ◽

Medical Records ◽

Chronic Conditions ◽

Claim Data ◽

Hospital Charges ◽

Multiple Chronic Conditions ◽

Health Claim ◽

Study Objective ◽

Health Related

The study objective was to (1) develop a statistical model that creates a novel patient engagement score (PES) from electronic medical records (EMR) and health claim data, and (2) validate this developed score using health-related outcomes and charges of patients with multiple chronic conditions (MCCs). This study used 2014-16 EMR and health claim data of patients with MCCs from Sanford Health. Patient engagement score was created based on selected patients’ engagement behaviors using Gaussian finite mixture model. The PES was validated using multiple logistic and linear regression analyses to examine the associations between the PES and health-related outcomes, and hospital charges, respectively. Patient engagement score was generated from 5095 patient records and included low, medium, and high levels of patient engagement. The PES was a significant predictor for low-density lipoprotein, emergency department visit, hemoglobin A1c, estimated glomerular filtration rate, hospitalization, and hospital charge. The PES derived from patient behaviors recorded in EMR and health claim data can potentially serve as a patient engagement measure. Further study is needed to refine and validate the newly developed score.

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